Section and Information to IncludeIntroduction (patient and problem)Explain who the patient is (Age, gender, etc.)Explain what the problem is (What were they diagnosed with, or what happened?)Introduce your main argument (What should you as a nurse focus on or do?)PathophysiologyExplain the disease (What are the symptoms? What causes it?)HistoryExplain what health problems the patient has (Have they been diagnosed with other diseases?)Detail any and all previous treatments (Have they had any prior surgeries or are they on medication?)Nursing Physical AssessmentList all the patient’s health stats in sentences with specific numbers/levels (Blood pressure, bowel sounds, ambulation, etc.)Related TreatmentsExplain what treatments the patient is receiving because of their diseaseNursing Diagnosis & Patient GoalExplain what your nursing diagnosis is (What is the main problem for this patient? What need to be addressed?)Explain what your goal is for helping the patient recover (What do you want to change for the patient?)Nursing InterventionsExplain how you will accomplish your nursing goals, and support this with citations (Reference the literature)EvaluationExplain how effective the nursing intervention was (What happened after your nursing intervention? Did the patient get better?)RecommendationsExplain what the patient or nurse should do in the future to continue recovery/improvement
